The children of the mentally ill are at increased risk of developing mental-health issues themselves, yet they are continually under-serviced.

Psychiatrist Dr. Simon Davidson says bureaucracy has created an artificial divide between the mental health system serving children and adolescents and the one serving adults.

By:Joanna SmithOttawa Bureau, Published on Fri Oct 12 2012

OTTAWA—She was perched on the couch, afraid to speak with the stranger who had come to visit, too frightened to interact with her own children.

The symptoms started soon after the birth of her second child, but the schizophrenia diagnosis was only coming now.

The youngest, a 3-year-old girl, was unclothed; the 5-year-old boy was trying to feed his mother raisins.

“He was the only adult in the house,” says Tatiana Wyse, now an early intervention family worker with the Schizophrenia Society of Ontario. Wyse met the boy when a child protection agency referred his family to her years ago.

“There was nobody there to protect them,” she

Yet, these children and teens are consistently under-serviced — and often outright ignored — by health and social systems.

Even the long-awaited national mental-health strategy — a 152-page tome urging an increase of $4 billion in mental-health spending over the next decade — devotes only a single paragraph to them. The report, released in May by the Mental Health Commission of Canada, calls for targeted prevention programs for children at risk — but it fails to describe what they would look like or who should provide them.

One explanation lies at the very heart of the mental-health system and what it is designed to do: treat the illness of the primary patient.

Elaine Mordoch believes the system does not pay enough attention to whether adult patients are parents and what that means for their children.

Years ago, she was working as a nurse in the acute psychiatry ward when the police brought in a woman who was in the midst of a mental-health crisis.

Mordoch discovered the woman had three children and asked the police officer what had happened to them.

“They’re as nuts as she is,” was the reply.

Nearly two decades later, the memory helps drive her research into how children of the mentally ill perceive and cope with their challenging situation in life.

“I think that the system is largely still organized around the biomedical model,” says Mordoch, now an assistant professor in the faculty of nursing at the University of Manitoba.

“The system and the people who are in the system have often been educated to look at the illness and not really look at the whole person.”

Dr. Simon Davidson, a psychiatrist and chief of specialized mental-health care for children and youth served by the Children’s Hospital of Eastern Ontario and The Royal Ottawa Mental Health Care Centre, believes there is a bureaucratic divide between the mental-health system for children and youth and the one for adults.

“There is this artificial schism created by bureaucracy, where adults with mental illness go to adult facilities and kids to kids facilities,” says Davidson. Like many in his field, he bemoans how this affects children living with mental illness as they “age out” of the pediatric system and struggle to find appropriate care as adults.

An obvious side effect of treating parents in isolation is that their children — the family members who are most affected by the illness — do not come to the attention of the child and adolescent mental-health system or child welfare agencies until they are already in distress.

“My experience is that we are missing these kids, without a doubt,” says Dr. Sabina Abidi, a child and adolescent psychiatrist at the IWK Health Centre in Halifax.

While Abidi is part of a collaborative program that aims to smooth the transition between the pediatric and adult mental system for patients with schizophrenia — and therefore pays special attention to how the children of adult patients are faring — she knows that things do not usually work that way.

“When I chat with colleagues who are in primary care, who are dealing with adults who have mental-health problems, who also have children, we don’t get notified about those kids until things have already developed,” says Abidi. “Kids will be referred to us . . . with anxiety, depression, school refusal (and) dysfunction, whatever it happens to be, after the fact, after onset, as opposed to preventively. It’s a huge miss.”

The fractured systems also tend to work at cross purposes.

Dr. Mary Seeman, a professor emerita in the psychiatry department at the University of Toronto, says the professional silos created within the mental-health community — extending to the different journals they read, the different conferences they attend and the different viewpoints they hold — also create different loyalties.

“Those who are looking after the mothers want the best for the mothers and often identify with the mothers,” says Seeman, who has treated and studied women with schizophrenia. “And, being very sympathetic to the mothers, they of course want children at home with them. They don’t want them to be separated from their kids, whereas those who are looking after children see the children’s best interests and wonder whether having a mother who is prone to psychotic illness is in fact the best things for the children.”

Provincial child protection legislation allows caseworkers to look at mitigating factors and come up with a plan that suits the needs and abilities of individual families, says Rowden. Mental health issues involving adult caregivers are present in about 25 per cent of the cases investigated by children’s aid societies in Ontario, she adds.

“Mental health on its own is absolutely not a reason for our involvement and would not be a reason that we are intervening in terms of the parenting role with the child,” says Rowden.

“We’re looking more functionally at: how is that mom doing in taking care of her kids? There are many very depressed people in this world who are absolutely fantastic parents and so it’s not the mental-health issue that’s the issue. It’s whether or not the child is safe, whether they are well cared for, and they are looking to make sure there are no signs of abuse, risk of neglect and exposure to harm.”

Rowden noted child welfare agencies in Ontario investigate about 85,000 cases in a given year, but as of March 31 there were approximately 17,000 children in care, meaning the majority of children remain at home while the family works to fulfill its plan.

A paper published last year by the Western New England University School of Law, in Springfield, Mass., raised important questions about the ability of parents with mental illness to meet the conditions imposed by child welfare agencies in the United States, leading to a termination of parental rights that could have been avoided with more appropriate services.

Jeanne Kaiser, the associate professor of legal research and writing who authored the paper, described a case on appeal. She represented a mother with mental illness who had had her parental rights terminated after failing to meet the demands of the child welfare agency. These demands included having a parent aide help her tidy up her messy home and attending parenting classes.

The parent aide discontinued the service, after deeming the mother “impossible” to work with. The mother refused to let anyone clear away the paper she claimed she needed to prosecute “the enemies” that had “invaded” her home.

She dropped the parenting class after going only once, believing the other parents were making fun of her.

Kaiser uses this example to illustrate how the services provided do not always meet the needs of parents with mental illness.

Imagine a woman in a parenting group where other parents are concerned about how to soothe a crying newborn while she is concerned about soothing the voices in her head.

So, Kaiser argues, it is unfair to use them as conditions for keeping the children at home.

Rowden says that, in Ontario, plans are developed in collaboration with the family.

“They recognize there are limitations to what they can do and they are really smart to partner with community-based organizations that can fill the gap of continuum of service,” says Cooper, whose organization runs an educational support group for children and siblings of people living with mental illness.

But Rowden acknowledges that appropriate services can be hard to come by.

“Access to service is a huge issue and one of our priority concerns is not just services for children. It’s the services for the families to prevent the children from having to come into care,” she says.

This project was funded by a Canadian Institutes for Health Research (CIHR) Journalism Award.

What do you think is wrong? Contact reporter Joanna Smith at jsmith@thestar.ca or (613) 237-4231.